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Infusion providers take Medicare patients ‘case by case’

YARMOUTH, Maine – One of the leading providers of home infusion therapy has stopped taking new Medicare patients and others are likely to follow suit if a “payment gap” is not closed.

“We are not able to take these patients that are directly impacted on our service and provide them the level of care that we deliver for the level of reimbursement that we make,” said Paul Mastrapa, CEO of Option Care, which is still caring for its active patients. “We are working with patients to get them referrals.”

As of Jan. 1, per a provision in the 21st Century Cures Act, Medicare pays for Part B infusion drugs under an average sales price model, a move that reduces payments so drastically that, essentially, they no longer cover services. Another provision in the act provides payments for these services, but not until 2021.

Infusion stakeholders have been pushing back hard on the change. A letter circulated by the National Home Infusion Association urging lawmakers to act quickly to address the “payment gap” garnered 170 signatures. The association is planning to track how many of its members may stop accepting new Medicare patients or stop serving them altogether, says Ken van Pool, vice president of legislative affairs.

“We are hearing from some members that they are holding off on taking new patients and some are working to transfer their patients out,” he said.

In New York state, which has a heavy managed care population, the impact has been milder, but no less challenging.

“We always do a case-by-case analysis,” said Gregory LoPresti, senior vice president and CEO of Clinton, N.Y.-based Upstate HomeCare. “We try to work with the patient; we try to get them on cheaper drugs.”

LoPresti has been preparing for the change since at least last summer.

“It’s never a good thing to have a unilateral change where they cut the drugs and they know there’s a technical component to this,” he said. “It’s irresponsible.”

Stakeholders have made inroads in the past year or so in their years-long quest for better Medicare coverage, but the industry really needs a long-term solution, says Mastrapa, who has taken the lead on Keep My Infusion Care at Home, a coalition charged with sharing stories of the impact of the changes on patients.

“We have to clearly articulate and share what is the value of what we do,” he said. “Any provider no matter how big or small, needs to take up arms to address this.”